A Comprehensive Review on Oculomotor Nerve Palsy; Diagnosis and Management Strategies
Abstract
The third cranial nerve (oculomotor nerve) plays an essential role in the function of ocular movement and mainly innervates the inferior oblique, medial rectus, inferior rectus, superior rectus, levator palpebrae, pupillary sphincter, and ciliary muscle. The most frequent clinical manifestations of oculomotor nerve palsy are ophthalmoplegia, ptosis, pupillary dysfunction, and diplopia. The etiology of oculomotor nerve palsy is complex, including congenital tumors, craniocerebral trauma, intracranial inflammation, diabetes, intracranial aneurysm, cerebrovascular infarction or hemorrhagic disease, myasthenia gravis, multiple myeloma demyelinating diseases, and other uncommon causes. Each etiology of oculomotor nerve palsy has its corresponding clinical features. The present article comprehensively reviews the common etiologies of oculomotor nerve palsy and the corresponding clinical manifestations and treatment methods in order to help practitioners for the prompt and accurate clinical diagnosis of the causes and effective management plan.
1. Margolin E, Freund P. A review of third nerve palsies. International Ophthalmology Clinics. 2019;59(3):99-112.
2. Green W, Hackett E, Schlezinger N. Neuro-ophthalmologic evaluation of oculomotor nerve paralysis. Archives of ophthalmology. 1964;72(2):154-67.
3. Margolin E, Freund P. Third Nerve Palsies. International ophthalmology clinics. 2019;59(3):99-112.
4. Fang C, Leavitt JA, Hodge DO, Holmes JM, Mohney BG, Chen JJ. Incidence and etiologies of acquired third nerve palsy using a population-based method. JAMA ophthalmology. 2017;135(1):23-8.
5. Keane JR. Third nerve palsy: analysis of 1400 personally-examined inpatients. Canadian journal of neurological sciences. 2010;37(5):662-70.
6. Jung EH, Kim S-J, Lee JY, Cho B-J. The incidence and etiologies of third cranial nerve palsy in Koreans: A 10-year Nationwide Cohort Study. Ophthalmic Epidemiology. 2020;27(6):460-7.
7. Raza HK, Chen H, Chansysouphanthong T, Cui G. The aetiologies of the unilateral oculomotor nerve palsy: a review of the literature. Somatosensory & motor research. 2018;35(3-4):229-39.
8. Singh A, Bahuguna C, Nagpal R, Kumar B. Surgical management of third nerve palsy. Oman Journal of Ophthalmology. 2016;9(2):80.
9. Schumacher-Feero LA, Yoo K, Solari FM, Biglan AW. Third cranial nerve palsy in children. American journal of ophthalmology. 1999;128(2):216-21.
10. Yanovitch T, Buckley E. Diagnosis and management of third nerve palsy. Current opinion in ophthalmology. 2007;18(5):373-8.
11. Rush JA, Younge BR. Paralysis of cranial nerves III, IV, and VI: cause and prognosis in 1,000 cases. Archives of ophthalmology. 1981;99(1):76-9.
12. Berlit P. Isolated and combined pareses of cranial nerves III, IV and VI a retrospective study of 412 patients. Journal of the neurological sciences. 1991;103(1):10-5.
13. Bruce BB, Biousse V, Newman NJ, editors. Third nerve palsies. Seminars in neurology; 2007: Copyright© 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New ….
14. Kasner SE, Liu GT, Galetta SL. Neuro-ophthalmologic aspects of aneurysms. Neuroimaging clinics of North America. 1997;7(4):679-92.
15. Etame AB, Bentley JN, Pandey AS. Acute expansion of an asymptomatic posterior communicating artery aneurysm resulting in oculomotor nerve palsy. Case Reports. 2013;2013:bcr2013010134.
16. Lee S-H, Lee S-S, Park K-Y, Han S-H. Isolated oculomotor nerve palsy: diagnostic approach using the degree of external and internal dysfunction. Clinical neurology and neurosurgery. 2002;104(2):136-41.
17. Chen PR, Amin-Hanjani S, Albuquerque FC, McDougall C, Zabramski JM, Spetzler RF. Outcome of oculomotor nerve palsy from posterior communicating artery aneurysms: comparison of clipping and coiling. Neurosurgery. 2006;58(6):1040-6.
18. Khan S, Agrawal A, Hailey C, Smith T, Gokhale S, Alexander M, et al. Effect of surgical clipping versus endovascular coiling on recovery from oculomotor nerve palsy in patients with posterior communicating artery aneurysms: a retrospective comparative study and meta-analysis. Asian journal of neurosurgery. 2013;8(3):117.
19. Gaberel T, Borha A, di Palma C, Emery E. Clipping versus coiling in the management of posterior communicating artery aneurysms with third nerve palsy: a systematic review and meta-analysis. World Neurosurgery. 2016;87:498-506. e4.
20. Stiebel-Kalish H, Maimon S, Amsalem J, Erlich R, Kalish Y, Rappaport ZH. Evolution of oculomotor nerve paresis after endovascular coiling of posterior communicating artery aneurysms: a neuro-ophthalmological perspective. Neurosurgery. 2003;53(6):1268-74.
21. Brigui M, Chauvet D, Clarençon F, Degos V, Sourour N-A, Nouet A, et al. Recovery from oculomotor nerve palsy due to posterior communicating artery aneurysms: results after clipping versus coiling in a single-center series. Acta neurochirurgica. 2014;156(5):879-84.
22. Mino M, Yoshida M, MoriTa T, ToMinaga T. Outcomes of oculomotor nerve palsy caused by internal carotid artery aneurysm: comparison between microsurgical clipping and endovascular coiling. Neurologia medico-chirurgica. 2015;55(12):885-90.
23. Binyamin TR, Dahlin BC, Waldau B. Resolution of third nerve palsy despite persistent aneurysmal mass effect after flow diversion embolization of posterior communicating artery aneurysms. Journal of Clinical Neuroscience. 2016;31:207-9.
24. Wang S, Yang J, Zhang G, Feng Y, Wang F, Zhou P. Effect of mecobalamin treatment on the recovery of patients with posterior communicating artery aneurysm inducing oculomotor nerve palsy after operation. European Review for Medical & Pharmacological Sciences. 2015;19(14):2603-7.
25. Leivo S, Hernesniemi J, Luukkonen M, Vapalahti M. Early surgery improves the cure of aneurysm-induced oculomotor palsy. Surgical neurology. 1996;45(5):430-4.
26. Jo Y-S, Kim SK, Kim DH, Kim J-H, Na S-J. Complete oculomotor nerve palsy caused by direct compression of the posterior cerebral artery. Journal of Stroke and Cerebrovascular Diseases. 2015;24(7):e189-e90.
27. Shimizu M, Tozaka N, Ishii A, Mamada N, Terada M, Takuma H, et al. Third nerve palsy due to local inflammation associated with vascular compression: A case series. Journal of the Neurological Sciences. 2016;367:365-7.
28. Ogawa K, Suzuki Y, Takahashi K, Kamei S, Ishikawa H. Clinical study of eleven patients with midbrain infarction-induced oculomotor nerve palsy. Journal of Stroke and Cerebrovascular Diseases. 2016;25(7):1631-8.
29. Vemmos K, Tsivgoulis G, Spengos K, Zakopoulos N, Synetos A, Manios E, et al. U‐shaped relationship between mortality and admission blood pressure in patients with acute stroke. Journal of internal medicine. 2004;255(2):257-65.
30. Muthyala T, Bagga R, Saha SC, Saha PK, Gainder S, Lal V, et al. Isolated oculomotor nerve palsy with complete recovery in eclampsia: a rare presentation. Journal of Obstetrics and Gynaecology. 2016;36(7):848-9.
31. Weber RB, Daroff RB, Mackey EA. Pathology of oculomotor nerve palsy in diabetics. Neurology. 1970;20(8):835-.
32. Bortolami R, D'Alessandro R, Manni E. The origin of pain in'ischemic-diabetic'third-nerve palsy. Archives of neurology. 1993;50(8):795-.
33. Jacobson DM. Pupil involvement in patients with diabetes-associated oculomotor nerve palsy. Archives of ophthalmology. 1998;116(6):723-7.
34. Venkatesan P, Gnanashanmugam G, Parimalam N, Pranesh M. Diabetes plus third nerve palsy not always diabetic third nerve palsy. Journal of Postgraduate Medicine. 2015;61(1):50.
35. Benzekri R, Hage R, Merle H. Case report: third cranial nerve palsy in the setting of Chikungunya virus infection. The American journal of tropical medicine and hygiene. 2016;95(1):180.
36. Drenckhahn A, Spors B, Knierim E. Acute isolated partial oculomotor nerve palsy due to Lyme neuroborreliosis in a 5 year old girl. European Journal of Paediatric Neurology. 2016;20(6):977-9.
37. Okawa S, Sugawara M, Takahashi S, Otani T, Hashimoto M, Kusunoki S, et al. Tolosa-hunt syndrome associated with cytomegalovirus infection. Internal Medicine. 2013;52(10):1121-4.
38. Muthu P, Pritty P. Mild head injury with isolated third nerve palsy. Emergency Medicine Journal. 2001;18(4):310-1.
39. Bateman JR, Murty P, Forbes M, Collier KY, Tememe D, de Marchena O, et al. Pupil-sparing third nerve palsies and hemiataxia: Claude’s and reverse Claude’s syndrome. Journal of Clinical Neuroscience. 2016;28:178-80.
40. Mishra A, Aggarwal S, Vichare N, Singh A. Isolated unilateral oculomotor nerve palsy following a mild head injury. Medical Journal, Armed Forces India. 2015;71(Suppl 2):S620.
41. Schumacher-Feero LA, Yoo K, Solari F, Biglan AW. Results following treatment of third cranial nerve palsy in children. Transactions of the American Ophthalmological Society. 1998;96:455.
42. Mudgil AV, Repka MX. Ophthalmologic outcome after third cranial nerve palsy or paresis in childhood. Journal of American Association for Pediatric Ophthalmology and Strabismus. 1999;3(1):2-8.
43. Rose LV, Elder JE. Management of congenital elevation deficiency due to congenital third nerve palsy and monocular elevation deficiency. Clinical & Experimental Ophthalmology. 2007;35(9):840-6.
44. Sukhija J, Kaur S, Singh U. Nasal lateral rectus transposition combined with medial rectus surgery for complete oculomotor nerve palsy. Journal of American Association for Pediatric Ophthalmology and Strabismus. 2014;18(4):395-6.
45. Gokyigit B, Akar S, Satana B, Demirok A, Yilmaz OF. Medial transposition of a split lateral rectus muscle for complete oculomotor nerve palsy. Journal of American Association for Pediatric Ophthalmology and Strabismus. 2013;17(4):402-10.
46. Lee SH, Chang JH. Medial rectus muscle anchoring in complete oculomotor nerve palsy. Journal of American Association for Pediatric Ophthalmology and Strabismus. 2015;19(5):465-8.
47. Kumar K, Ahmed R, Bajantri B, Singh A, Abbas H, Dejesus E, Khan RR, Niazi M, Chilimuri S. Tumors presenting as multiple cranial nerve palsies. Case reports in neurology. 2017 Jul 11;9(1):54-61.
48. Panda BB, Parija S, Mallick J, Pujahari S. Oculomotor nerve palsy as a rare presentation and first sign of multiple myeloma. Journal of Clinical and Diagnostic Research: JCDR. 2016;10(5):ND01.
2. Green W, Hackett E, Schlezinger N. Neuro-ophthalmologic evaluation of oculomotor nerve paralysis. Archives of ophthalmology. 1964;72(2):154-67.
3. Margolin E, Freund P. Third Nerve Palsies. International ophthalmology clinics. 2019;59(3):99-112.
4. Fang C, Leavitt JA, Hodge DO, Holmes JM, Mohney BG, Chen JJ. Incidence and etiologies of acquired third nerve palsy using a population-based method. JAMA ophthalmology. 2017;135(1):23-8.
5. Keane JR. Third nerve palsy: analysis of 1400 personally-examined inpatients. Canadian journal of neurological sciences. 2010;37(5):662-70.
6. Jung EH, Kim S-J, Lee JY, Cho B-J. The incidence and etiologies of third cranial nerve palsy in Koreans: A 10-year Nationwide Cohort Study. Ophthalmic Epidemiology. 2020;27(6):460-7.
7. Raza HK, Chen H, Chansysouphanthong T, Cui G. The aetiologies of the unilateral oculomotor nerve palsy: a review of the literature. Somatosensory & motor research. 2018;35(3-4):229-39.
8. Singh A, Bahuguna C, Nagpal R, Kumar B. Surgical management of third nerve palsy. Oman Journal of Ophthalmology. 2016;9(2):80.
9. Schumacher-Feero LA, Yoo K, Solari FM, Biglan AW. Third cranial nerve palsy in children. American journal of ophthalmology. 1999;128(2):216-21.
10. Yanovitch T, Buckley E. Diagnosis and management of third nerve palsy. Current opinion in ophthalmology. 2007;18(5):373-8.
11. Rush JA, Younge BR. Paralysis of cranial nerves III, IV, and VI: cause and prognosis in 1,000 cases. Archives of ophthalmology. 1981;99(1):76-9.
12. Berlit P. Isolated and combined pareses of cranial nerves III, IV and VI a retrospective study of 412 patients. Journal of the neurological sciences. 1991;103(1):10-5.
13. Bruce BB, Biousse V, Newman NJ, editors. Third nerve palsies. Seminars in neurology; 2007: Copyright© 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New ….
14. Kasner SE, Liu GT, Galetta SL. Neuro-ophthalmologic aspects of aneurysms. Neuroimaging clinics of North America. 1997;7(4):679-92.
15. Etame AB, Bentley JN, Pandey AS. Acute expansion of an asymptomatic posterior communicating artery aneurysm resulting in oculomotor nerve palsy. Case Reports. 2013;2013:bcr2013010134.
16. Lee S-H, Lee S-S, Park K-Y, Han S-H. Isolated oculomotor nerve palsy: diagnostic approach using the degree of external and internal dysfunction. Clinical neurology and neurosurgery. 2002;104(2):136-41.
17. Chen PR, Amin-Hanjani S, Albuquerque FC, McDougall C, Zabramski JM, Spetzler RF. Outcome of oculomotor nerve palsy from posterior communicating artery aneurysms: comparison of clipping and coiling. Neurosurgery. 2006;58(6):1040-6.
18. Khan S, Agrawal A, Hailey C, Smith T, Gokhale S, Alexander M, et al. Effect of surgical clipping versus endovascular coiling on recovery from oculomotor nerve palsy in patients with posterior communicating artery aneurysms: a retrospective comparative study and meta-analysis. Asian journal of neurosurgery. 2013;8(3):117.
19. Gaberel T, Borha A, di Palma C, Emery E. Clipping versus coiling in the management of posterior communicating artery aneurysms with third nerve palsy: a systematic review and meta-analysis. World Neurosurgery. 2016;87:498-506. e4.
20. Stiebel-Kalish H, Maimon S, Amsalem J, Erlich R, Kalish Y, Rappaport ZH. Evolution of oculomotor nerve paresis after endovascular coiling of posterior communicating artery aneurysms: a neuro-ophthalmological perspective. Neurosurgery. 2003;53(6):1268-74.
21. Brigui M, Chauvet D, Clarençon F, Degos V, Sourour N-A, Nouet A, et al. Recovery from oculomotor nerve palsy due to posterior communicating artery aneurysms: results after clipping versus coiling in a single-center series. Acta neurochirurgica. 2014;156(5):879-84.
22. Mino M, Yoshida M, MoriTa T, ToMinaga T. Outcomes of oculomotor nerve palsy caused by internal carotid artery aneurysm: comparison between microsurgical clipping and endovascular coiling. Neurologia medico-chirurgica. 2015;55(12):885-90.
23. Binyamin TR, Dahlin BC, Waldau B. Resolution of third nerve palsy despite persistent aneurysmal mass effect after flow diversion embolization of posterior communicating artery aneurysms. Journal of Clinical Neuroscience. 2016;31:207-9.
24. Wang S, Yang J, Zhang G, Feng Y, Wang F, Zhou P. Effect of mecobalamin treatment on the recovery of patients with posterior communicating artery aneurysm inducing oculomotor nerve palsy after operation. European Review for Medical & Pharmacological Sciences. 2015;19(14):2603-7.
25. Leivo S, Hernesniemi J, Luukkonen M, Vapalahti M. Early surgery improves the cure of aneurysm-induced oculomotor palsy. Surgical neurology. 1996;45(5):430-4.
26. Jo Y-S, Kim SK, Kim DH, Kim J-H, Na S-J. Complete oculomotor nerve palsy caused by direct compression of the posterior cerebral artery. Journal of Stroke and Cerebrovascular Diseases. 2015;24(7):e189-e90.
27. Shimizu M, Tozaka N, Ishii A, Mamada N, Terada M, Takuma H, et al. Third nerve palsy due to local inflammation associated with vascular compression: A case series. Journal of the Neurological Sciences. 2016;367:365-7.
28. Ogawa K, Suzuki Y, Takahashi K, Kamei S, Ishikawa H. Clinical study of eleven patients with midbrain infarction-induced oculomotor nerve palsy. Journal of Stroke and Cerebrovascular Diseases. 2016;25(7):1631-8.
29. Vemmos K, Tsivgoulis G, Spengos K, Zakopoulos N, Synetos A, Manios E, et al. U‐shaped relationship between mortality and admission blood pressure in patients with acute stroke. Journal of internal medicine. 2004;255(2):257-65.
30. Muthyala T, Bagga R, Saha SC, Saha PK, Gainder S, Lal V, et al. Isolated oculomotor nerve palsy with complete recovery in eclampsia: a rare presentation. Journal of Obstetrics and Gynaecology. 2016;36(7):848-9.
31. Weber RB, Daroff RB, Mackey EA. Pathology of oculomotor nerve palsy in diabetics. Neurology. 1970;20(8):835-.
32. Bortolami R, D'Alessandro R, Manni E. The origin of pain in'ischemic-diabetic'third-nerve palsy. Archives of neurology. 1993;50(8):795-.
33. Jacobson DM. Pupil involvement in patients with diabetes-associated oculomotor nerve palsy. Archives of ophthalmology. 1998;116(6):723-7.
34. Venkatesan P, Gnanashanmugam G, Parimalam N, Pranesh M. Diabetes plus third nerve palsy not always diabetic third nerve palsy. Journal of Postgraduate Medicine. 2015;61(1):50.
35. Benzekri R, Hage R, Merle H. Case report: third cranial nerve palsy in the setting of Chikungunya virus infection. The American journal of tropical medicine and hygiene. 2016;95(1):180.
36. Drenckhahn A, Spors B, Knierim E. Acute isolated partial oculomotor nerve palsy due to Lyme neuroborreliosis in a 5 year old girl. European Journal of Paediatric Neurology. 2016;20(6):977-9.
37. Okawa S, Sugawara M, Takahashi S, Otani T, Hashimoto M, Kusunoki S, et al. Tolosa-hunt syndrome associated with cytomegalovirus infection. Internal Medicine. 2013;52(10):1121-4.
38. Muthu P, Pritty P. Mild head injury with isolated third nerve palsy. Emergency Medicine Journal. 2001;18(4):310-1.
39. Bateman JR, Murty P, Forbes M, Collier KY, Tememe D, de Marchena O, et al. Pupil-sparing third nerve palsies and hemiataxia: Claude’s and reverse Claude’s syndrome. Journal of Clinical Neuroscience. 2016;28:178-80.
40. Mishra A, Aggarwal S, Vichare N, Singh A. Isolated unilateral oculomotor nerve palsy following a mild head injury. Medical Journal, Armed Forces India. 2015;71(Suppl 2):S620.
41. Schumacher-Feero LA, Yoo K, Solari F, Biglan AW. Results following treatment of third cranial nerve palsy in children. Transactions of the American Ophthalmological Society. 1998;96:455.
42. Mudgil AV, Repka MX. Ophthalmologic outcome after third cranial nerve palsy or paresis in childhood. Journal of American Association for Pediatric Ophthalmology and Strabismus. 1999;3(1):2-8.
43. Rose LV, Elder JE. Management of congenital elevation deficiency due to congenital third nerve palsy and monocular elevation deficiency. Clinical & Experimental Ophthalmology. 2007;35(9):840-6.
44. Sukhija J, Kaur S, Singh U. Nasal lateral rectus transposition combined with medial rectus surgery for complete oculomotor nerve palsy. Journal of American Association for Pediatric Ophthalmology and Strabismus. 2014;18(4):395-6.
45. Gokyigit B, Akar S, Satana B, Demirok A, Yilmaz OF. Medial transposition of a split lateral rectus muscle for complete oculomotor nerve palsy. Journal of American Association for Pediatric Ophthalmology and Strabismus. 2013;17(4):402-10.
46. Lee SH, Chang JH. Medial rectus muscle anchoring in complete oculomotor nerve palsy. Journal of American Association for Pediatric Ophthalmology and Strabismus. 2015;19(5):465-8.
47. Kumar K, Ahmed R, Bajantri B, Singh A, Abbas H, Dejesus E, Khan RR, Niazi M, Chilimuri S. Tumors presenting as multiple cranial nerve palsies. Case reports in neurology. 2017 Jul 11;9(1):54-61.
48. Panda BB, Parija S, Mallick J, Pujahari S. Oculomotor nerve palsy as a rare presentation and first sign of multiple myeloma. Journal of Clinical and Diagnostic Research: JCDR. 2016;10(5):ND01.
| Issue | Articles in Press | |
| Section | Review Article(s) | |
| Keywords | ||
| Third nerve palsy; Oculomotor nerve palsy; Strabismus; Ptosis | ||
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Shakor Y, Moravvej R, Majdi A, Bahreini R. A Comprehensive Review on Oculomotor Nerve Palsy; Diagnosis and Management Strategies. jmr. 2025;(-).
